Adoptees Affidavit And Petition To Appoint A Confidential Intermediary {WYCAI-1}

WYCAI-1 (REV. 1/27/11) STATE OF WYOMING ) ) COUNTY OF ________________________) IN THE MATTER OF THE ADOPTION OF IN THE DISTRICT COURT SS ______________JUDICIAL DISTRICT CASE # _________________________ ADOPTEE'S AFFIDAVIT AND PETITION TO APPOINT A CONFIDENTIAL INTERMEDIARY, PURSUANT TO W.S. 1-22-203(b) ) ) ) ) ) _______________________________________) ___________________________________________, being first duly sworn, on oath, petitions and says: (petitioner's name) I was born on ___________________________ in _____________________________________, (date of birth) (city/county) and I am 18 years of age or older. My current telephone numbers are: (home) _______________________(work) _____________________ (cell) ____________________________. E-mail address______________________________________ Mailing address_______________________________________________________________________. I was adopted by ______________________________________________________________in ______________________County, Wyoming, on or about _____________________________________ (date of adoption) I know the following about my birth parents or relatives: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ I am seeking my birth parents or relatives because: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ I am/am not living with my adoptive parents. I, therefore, petition this court and respectfully request that an order be entered appointing a confidential intermediary, pursuant to W.S. 1-22-203(b) and that the confidential intermediary be allowed to inspect and copy, at the petitioner's expense, the pertinent adoption files of the court, governmental agencies, adoption agencies and hospitals. DATED this ______________day of ___________________________________________, 20 _______. _____________________________________________ (Petitioner's signature) SUBSCRIBED AND SWORN to before me this __________ day of __________________, 20________. My commission expires: ___________________________________ _____________________________________________ NOTARY PUBLIC OR DEPUTY CLERK OF COURT American LegalNet, Inc. www.FormsWorkFlow.com